Department of the Treasury – Internal Revenue Service

Form 13614
(Rev. August 2007)
You (and Spouse) will need:
• Proof of Identity
• Copies of ALL W-2, 1098, 1099 forms
• Social Security (SSN) or Individual Tax
Identification Number (ITIN) for all
Individuals to be listed on the return
OMB # 1545-1964
Intake and Interview Sheet
• Child care provider’s identification number
• Banking information (checking and/or
savings account) for direct deposit/debit
• Amounts/dates of estimated or other tax
payments made, etc.
• Amounts of other income

Part I: Taxpayer Information

1. Your First Name M.I. Last Name 2. SSN or ITIN

3. Date of Birth 4. US Citizen or Resident Alien 5. Legally Blind 6. Totally and Permanently Disabled
(mm/dd/yyyy)
Yes No Yes No Yes No
7. Spouse’s First Name M.I. Last Name 8. SSN or ITIN

9. Date of Birth 10. US Citizen or Resident Alien 11. Legally Blind 12. Totally and Permanently Disabled
(mm/dd/yyyy)
Yes No Yes No Yes No
13. Address Apt # City State Zip Code

14. Phone Number and e-mail address 15. Can you or your spouse be claimed as a dependent
on the income tax return of any other person for 2007?
Phone: ( )
e-mail: Yes No

16. On December 31, 2007:

a. Were you: Single Legally Married Separated Divorced Widowed
b. If married, were you living together (with your husband/wife) on/after June 30, 2007? Yes No
c. Was your spouse deceased? If yes, provide the date of death. (mm/dd/yyyy)

17. Did you pay more than half the cost of keeping up the home for the year? Yes No

Part II. Family and Dependent Information – Do not include you or your spouse.
Print the name of everyone who lived in your home and outside your home that you supported during the year.
Name Date of Birth Social Security Relationship to Number of US Citizen, Is the dependent
(first, last) mm/dd/yyyy Number or ITIN you (son, months person Resident of US, a full time student
daughter, etc.) lived with you in Canada or Mexico born before 1989?
2007 (yes or no) (yes or no)
(a) (b) (c) (d) (e) (f) (g)

Paperwork Reduction Act Notice

The Paperwork Reduction Act requires that the IRS display an OMB control number on all public information requests. The OMB Control Number for this study is 1545-1964.
Also, if you have any comments regarding the time estimates associated with this study or suggestion on making this process simpler, please write to the Internal Revenue
Service, Tax Products Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave. NW, Washington, DC 20224.

Catalog Number 38836A Form 13614 (Rev. 8-2007)

Page 2 TO BE COMPLETED WITH CERTIFIED VOLUNTEER

 Volunteer Preparer Instructions: In order to complete an accurate return you must conduct a thorough interview. This intake
sheet does not constitute a complete interview. Remember to ask the taxpayer for all their documentation. Based on your
interview with the taxpayer be sure to note changes to information on the intake sheet. Confirm information on page 1 with taxpayer.

Use the decision trees in Publication 4012,

Volunteer Resource Guide while discussing the questions below with the taxpayer.

Part Ill. Filing Status & Dependency Determination

Based on the interview, the filing status of the taxpayer is: Single MFJ MFS* HOH QW
*Spouse Name Social Security Number

Yes No 1. Did you provide more than 50% of the support for the dependents claimed?
Yes No 2. Can anyone else claim any of these dependents on their income tax return?
Yes No 3. Were any of these dependents permanently and totally disabled in 2007?
Yes No 4. Did any of these dependents file a joint return for 2007?
5. Based on the interview, how many individuals qualify as dependents for this return?

COMMONLY USED INCOME AND EXPENSES

Part IV. Income – In 2007, did you (or your spouse) receive:
Yes No 1. Wages or Salary (include W-2s for all jobs worked during the year)
Yes No 2. Disability income
Yes No 3. Interest/Dividends from: checking or savings account, bonds, CDs, or brokerage account
Yes No 4. State tax refund (may be taxable if you itemized last year)
Yes No 5. Alimony income
Yes No 6. Tip income
Yes No 7. Pension and/or IRA distribution
Yes No 8. Unemployment (1099-G)
Yes No 9. Social Security or Railroad Retirement Benefits (1099-SSA or RRB)
Yes No 10. Self Employment Income - business, farm, hobby (1099-Misc or any earned income not
reported on W-2)
Yes No 11. Other Income such as gambling winnings, awards, prizes and Jury Duty pay, etc.

Part V. Adjustments – In 2007 did you (or your spouse) make:

Yes No 1. Contributions to IRA, 401k or other retirement account
Yes No 2. Alimony payments (if yes, you must provide the name and SSN of the recipient)
Yes No 3. Education related expenses

Part VI. Itemized Deductions – Did you (or your spouse) have 2007 expenses for:
Yes No 1. Un-reimbursed medical expenses
Yes No 2. Home mortgage payments (interest and taxes – see Form 1098)
Yes No 3. Charitable contributions

Part VII. Credits – In 2007 did you (or your spouse) have:
Yes No 1. Child/dependent care expenses that allow you (and your spouse-if MFJ) to work
Yes No 2. Educational expenses for you (or your spouse) and/or your dependents
Yes No 3. Retirement Contribution to a traditional IRA, Roth IRA or 401k as shown on Form W-2

Part VIII. Earned Income Tax Credit Determination – EITC Eligibility

Yes No 1. Was EITC previously disallowed? (if yes, taxpayer may not be eligible for EITC)
Yes No 2. Based on the interview, is the taxpayer qualified for EITC?

Catalog Number 38836A Page 2 Form 13614 (Rev. 8-2007)